Preparing for care pathways and skill mix
The recent British Dental Conference & Exhibition held in London was the setting for a Colgate Oral Health Network session entitled ‘Improving Periodontal Health in Practice: Preparing for care pathways and skill mix’.
The session was chaired by Eric Rooney, Consultant in Dental Public Health, and chair of Pathway Review Group, involved in devising care pathways being used within pilot programmes for the new dental contract in England. Dr Rooney gave some background to the context of care pathway approaches within pilots and what this may mean for the future.
Last October, it was announced the number of pilot practices would be increasing to around 100, and the original pilot sites will continue for a further year with some amends. Early learnings from original pilots can be viewed at the Department of Health web site https://www.gov.uk/government/publications/extension-to-dental-contract-pilot-scheme and states ‘Significant challenges remain, but both dental staff and patients have been overwhelmingly positive about the new approach to clinical care seen in the pilots. Further development is needed but we think a pathway approach should form a key part of any future contract’.
Dr Rooney went on to share a summary of what this means for the two groups of the population covering routine and urgent care. Routine care patients undergo an oral health assessment and receive tailor made prevention advice, dependant of the level of risk, using Delivering Better Oral Health guidance1 document for evidence based patient home care and dental professional interventions.
Dr Anousheh Alavi, Specialist in Periodontology and Colgate Scientific Affairs Manager, UK & Ireland then delivered the main session. Dr Alavi was involved in training the phase one pilot practices with regards to the perio pathway, and is also a member of the group reviewing care pathway outcomes after the first year.
Dr Alavi said she was looking to take the audience on a journey specifically in relation to periodontal care, and how we can make use of skill mix. This is something we all need to be aware of whether we have been involved in the pilot process or not, and we need to consider its implications now as we plan for the future.
The Periodontal Care Pathway builds from 3 domains of information
- Medical and social history, such as level of diabetes control and whether the patient is a smoker
- Clinical examination including BPE
- Other key factors which influence level of risk such as plaque score and extent of bleeding on probing (BOP)
Since pocket depths are historical, BOP is a more a current reflection of the extent of inflammation present. Using the traffic light system, the measurements taken will determine the patients overall level of risk. Dr Alavi also suggested those interested in finding more about BPE can visit the British Society of Periodontology website www.perio.org.uk.
All patients, irrespective of risk, require motivation and oral hygiene instruction. The latest Adult Dental Health Survey2 gives us broad measures at a population level and shows 66% of the adult population have visible plaque. The main point of trying to prevent periodontal disease is to remove the cause, and unless we have some measure of how much plaque there is to start with, we cannot assess risk and make a correct diagnosis. Also the treatment plan will not reflect the true level of risk that patient has.
Dr Alavi posed the question as to how are we going to deliver the advice to motivate patients, and what is the appropriate oral health advice? To deliver an optimum level of care, we need to combine evidence based information, patient factors and our clinical judgment. When all three elements come together, we deliver optimal care. We all have patients who are given advice without them acting on it. The key point is not just the delivery; we have a duty of care to ensure it works for our patients. The good news is Delivering Better Oral Health guidance1 also states the level of evidence which should give us confidence in the likely outcome when we transfer this information to our patients.
Adapting the perio care pathway to a team approach demonstrates how different team members can play key roles in overall patient care. If we take this to be a standardised way of delivery, in order to make the most of the team, we can identify any training gaps to fulfil now and so optimise what we can deliver both now and in the future. In terms of patient outcome, focusing on prevention utilising skill mix is the best practice model.
Where do we go from here? Following feedback the pathways are continually refined. Conveying evidence based advice to patients making it accessible to them is important for us to share and discuss in order to optimise patient delivery within our practice settings.
1. Delivering Better Oral Health-An evidence-based toolkit for prevention, published by the Department of Health, July 2009.
2. The Adult Dental Health Survey, 2009, NHS Information Centre for Health and Social Care